Healthcare Provider Details

I. General information

NPI: 1417985615
Provider Name (Legal Business Name): STEPHEN ROBERT KNAZIK DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 07/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 BEAUBIEN EMERGENCY DEPT - MAIN BUILDING CHILDRENS HOSPITAL OF MI
DETROIT MI
48201
US

IV. Provider business mailing address

3800 WOODWARD AVE SUITE 702
DETROIT MI
48201-2061
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-5260
  • Fax: 313-993-7166
Mailing address:
  • Phone: 313-262-1303
  • Fax: 313-262-1238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number5101009143
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: